Here's a question sent in recently by an Academy member, along with an answer provided by Mass General faculty.

QUESTION
I recently saw a first time pregnant 34 yo nurse practioner 8 weeks pregnant. She has a history of debilitating anxiety that has waxed and waned for the past 8 years. She was initially started on Celexa at 20 mg which caused a serotonin syndrome after 3 doses. That was discontinued and was placed on Effexor which was titrated up to 75 mg which provided benefit which she took for 6 months but had trouble weaning off. She prefers to remain off meds and functioned well until last year and had a recurrent bout of anxiety and was placed on Buspar and Ativan which she took rarely prn when needed and was helpful by her GP. In Jan. 2010 had return of incapacitating anxiety, panic (palpitations, naseau, diarrhea, insomnia). Her GP placed her on Atenolol 25 mg, and Ativan .5 at hs. She was started on Lexapro and titrated up to 10 mg., the combination was helpful.
Question: She is now 8 weeks pregnant, GP stopped all meds. Severe return of symptoms, not sleeping, naseous, vomiting, anxious. OB placed her on Phenergan which puts her to sleep but she cannot function during the day.
Solution? With the concerns regarding SSRIS and PPHN after the 20th week affecting <1%. Do you suggest a retrial on low dose Lexapro since she tolerated it and benefited from it ? Versus a trial on Prozac since it has been studied more yet she has never had a trial on? Or would you leave her off and use the atenolol and Vistaril?

I understand you cannot make an official recommendation but any guidance would be helpful. The articles I have read clump all the SSRIS together will make no statement regarding Lexapro as she has found it helpful in the past. The OBs here are reluctant due to the PPHN concern though the risk is low. With informed consent, I believe due to the level of her symptoms it would be helpful to treat with a low dose SSRI, possible Vistaril for her anxiety in the evening which might also help her naseau, and prn Ativan for extreme rare prn use for severe anxiety. Any guidance would be sincerely appreciated. With many thanks!


ANSWER
The dilemma of treating psychiatric disorders during pregnancy is one that is worthy of special consideration. Current available evidence informs us that there are potential deleterious effects to the developing fetus from exposure to medications as well as from untreated psychiatric illness. The decision as to whether or not to prescribe psychotropic medication should be made after a careful and thorough discussion with the patient delineating the nature of the psychiatric condition that is to be treated, the risks, benefits, and side effects of the medication(s), alternative treatments, as well as the risk of not treating a diagnosed anxiety or depressive disorder. An excellent resource on these questions as well as others related to management of psychiatric illness during pregnancy is www.womensmentalhealth.org, with particular attention paid to the library page for a list of references as well as to the summary page of psychiatric disorders during pregnancy.

With respect to the medications that were raised in the clinical question, the majority of studies suggest that the risk for teratogenesis when using SSRIs is negligible, with the exception of paroxetine. There also appears to be an association with poor perinatal outcomes, as demonstrated by increased crying, tremor, restlessness, and motor tone lasting one to four days in newborns exposed to SSRIs. The risk of persistent pulmonary hypertension of the newborn appears to be associated with SSRI exposure, though as mentioned, it appears to be less than one percent. These risks should be weighed against not treating the maternal psychiatric disorder and the association of maternal anxiety or depression and poor perinatal outcome, prematurity, and preeclampsia. There is more data related to the use of fluoxetine in pregnancy than other medications, although this does not necessarily mean that the risk is lower. The benefit of using a medication(s) that the patient has tolerated in the past and has demonstrated efficacy in ameliorating target symptoms may outweigh the benefits of a larger data set. However, this assumes that there are no clearly elevated risks associated with the treatment, underscoring the need for all pertinent information to be reviewed with each patient and their preferences respected.

The risk of prescribing benzodiazepines, e.g., lorazepam, during pregnancy remains controversial. Early studies suggested that there was a risk of specific malformations associated with exposure. However, more recent studies have put this into question. If there is a risk due to exposure, it is believed to be 0.7 percent and although this is higher than the baseline risk, it would still be a rare event. Buspirone does not have systematic data regarding its use during pregnancy and therefore it is not recommended.

As in the cases presented here, it is essential to review the known evidence, both risks and benefits, about specific psychotropic medications with patients and collaborate with their treating OB/GYN to decide on a mutually agreeable strategy for treating anxiety or depression. It is also critical to avoid sub-therapeutic dosing which exposes the fetus to the risks of medication and does not mitigate the risks of maternal anxiety and depression.


Reference:
www.womensmentalhealth.org